Sec. 22.6. (a) If a pharmacy benefit manager denies an appeal under section 22(a)(2) of this chapter, the appealing contracted pharmacy, pharmacy services administrative organization, or group purchasing organization may file a complaint with the department not later than thirty (30) days from the date of the denial. The department may request additional information from either party as necessary to resolve a complaint.

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Terms Used In Indiana Code 27-1-24.5-22.6

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Department: means "the department of insurance" of this state. See Indiana Code 27-1-2-3
  • pharmacy: means the physical location:

    Indiana Code 27-1-24.5-11

  • pharmacy benefit manager: means an entity that, on behalf of a health plan, state agency, insurer, managed care organization, or other third party payor:

    Indiana Code 27-1-24.5-12

  • pharmacy services administrative organization: means an organization that assists independent pharmacies and pharmacy benefit managers or health plans to achieve administrative efficiencies, including contracting and payment efficiencies. See Indiana Code 27-1-24.5-15
     (b) If a contracted pharmacy or pharmacy services administrative organization believes that its contract with a pharmacy benefit manager contains an unlawful contractual provision regarding reimbursement rates, the contracted pharmacy or pharmacy services administrative organization may file a complaint with the department.

     (c) A pharmacy benefit manager that receives written notice of a complaint filed under this section shall promptly conduct an investigation of the matters alleged in the complaint. Not later than twenty (20) business days after the date of the complaint, the pharmacy benefit manager shall provide to the department and the complaining party a written report containing the following information:

(1) The specific actions taken by the pharmacy benefit manager with respect to:

(A) the appeal, for a complaint filed under subsection (a); or

(B) the contract, for a complaint filed under subsection (b).

(2) A good faith estimate of the time required for a resolution of the complaint.

     (d) If a pharmacy believes that its contract with a pharmacy services administrative organization contains an unlawful contractual provision regarding reimbursement rates, the pharmacy may file a complaint with the department.

     (e) The department shall establish a process for complaints filed under this section.

As added by P.L.196-2021, SEC.25.

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